2019 Prior Authorizations (List of Prior Authorizations)

Transcription

1 Prior Authorization Last Updated: March 20, 2019 Effective Date: April 1, Prior Authorizations (List of Prior Authorizations) PLEASE READ CAREFULLY: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE PRIOR AUTHORIZATIONS ON DRUGS THAT WE COVER IN THIS PLAN. Note to existing members: Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, List of Covered Drugs, pharmacy and provider networks and copayments may change from time to time throughout the year and on January 1 of each year. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. You can get this information for free in other languages. Call IEHP (4347), 8am 8pm (PST) 7 days a week, including holidays.tty/tdd users should call The call is free. Usted puede obtener esta información gratis en otros idiomas. Llame al IEHP (4347), 8am 8pm (Hora del Pacífico), los 7 días de la semana, incluidos días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. H5355_CMC_19_

2 ABELCET ABELCET Other Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to the formulary alternative: conventional Amphotericin B. 1

3 ABILIFY MAINTENA ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING Other The member has a documented history of receiving oral aripiprazole without any clinically significant side effects. Additionally, the member has a documented trial and failure or medical reason (e.g. intolerance, hypersensitivity or contraindication) for not utilizing these therapies to manage their medical condition: Invega Sustenna, Invega Trinza or Risperdal Consta. 2

4 ABIRATERONE abiraterone Other Documentation of concurrent treatment with prednisone. Oncologist 3

5 ACITRETIN acitretin Other Dermatologist Failure or clinically significant adverse effects to two of the formulary alternatives: calcipotriene, clobetasol, cyclosporine, fluocinonide, methotrexate, or Tazorac. 4

6 ACTIMMUNE ACTIMMUNE Other Hematologist, Infectious Disease specialist, Oncologist, Orthopedist, Rheumatologist Subject to Part B vs Part D determination. 5

7 ADEFOVIR adefovir Other Gastroenterologist, Hepatologist, Infectious Disease specialist 6

8 ADEMPAS ADEMPAS Other Concurrent use of nitrates and PDE5 inhibitors. Cardiologist, Pulmonologist Until the end of calendar year For Pulmonary Arterial Hypertension only: Failure or clinically significant adverse effects to the formulary alternative: sildenafil. Other indication(s) do not require failure or clinically significant adverse effects to sildenafil. 7

9 ADHD dexmethylphenidate oral tablet dextroamphetamine oral tablet dextroamphetamine-amphetamine oral tablet methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic mg, 20 mg, 30 mg, 40 mg methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release Other 8

10 AFINITOR AFINITOR AFINITOR DISPERZ Other Oncologist, Neurologist Advanced renal cell carcinoma: Failure or clinically significant adverse effects to one of the formulary alternatives: Nexavar or Sutent. Advanced hormone receptor-positive, HER2 negative breast cancer in postmenopausal women: Use in combination with exemestane and failure or clinically significant adverse effects to one of the formulary alternatives: anastrozole or letrozole. 9

11 ALECENSA ALECENSA Other Documentation of anaplastic lymphoma kinase (ALK) positive. Oncologist 10

12 ALLI ALLI 60 MG CAPSULE STARTER PACK Covered Uses Other Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet. BMI greater than or equal to 27 kg/m2 with one or more comorbidity (e.g. coronary heart disease, dyslipidemia, hypertension, type 2 diabetes mellitus, sleep apnea), OR BMI greater than or equal to 30 kg/m2. Reauthorization: Documented weight loss of 5% during the first 6 month period and lack of side effects. Therapy beyond the first year can be authorized every 6 months with documentation of weight maintenance and lack of side effects. 6 months. 11

13 ALUNBRIG ALUNBRIG Other Documentation of anaplastic lymphoma kinase (ALK) positive. Oncologist Failure or clinically significant adverse effects to the formulary alternative: Xalkori. 12

14 ALYQ alyq Other Concurrent use of nitrates and PDE5 inhibitors. Cardiologist, Pulmonologist Failure or clinically significant adverse effects to the formulary alternative: sildenafil. 13

15 AMBISOME AMBISOME Other Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to the formulary alternative: conventional Amphotericin B. 14

16 AMITRIPTYLINE amitriptyline Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 15

17 AMOXAPINE amoxapine Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, nortriptyline, sertraline, or venlafaxine. 16

18 AMPHOTERICIN B amphotericin b Other Subject to Part B vs Part D determination. 17

19 ANADROL ANADROL-50 Other Hematologist, Oncologist 18

20 ANDROGENS ANDRODERM testosterone transdermal gel in metered-dose pump testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) testosterone transdermal solution in metered pump w/app Other Documented pretreatment serum testosterone levels less than the laboratory's lower reference limit within the recent 3 months 19

21 APOKYN APOKYN Other Failure or clinically significant adverse effects to two of the formulary alternatives: antiparkinson drugs such as amantadine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, ropinirole, or selegiline. 20

22 APREPITANT aprepitant Other 6 months. Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to one of the formulary 5-HT3 antagonist alternatives: ondansetron or granisetron except when the member is on any chemotherapy. 21

23 APTIOM APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 22

24 ARCALYST ARCALYST Other Concurrently taking any tumor necrosis factor (TNF)-blocking agents such as Enbrel, Humira, or Remicade. Approve if 12 years old or older. 23

25 ARIKAYCE ARIKAYCE Other Documentation of treatment failure with a combination antibacterial drug regimen for at least 6 months, as evidenced by not achieving negative sputum cultures. Infectious Disease specialist, Pulmonologist Subject to Part B vs Part D determination. 24

26 ARIPIPRAZOLE aripiprazole oral tablet Other Bipolar and Schizophrenia: Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 25

27 ARIPIPRAZOLE ODT aripiprazole oral tablet,disintegrating Other Bipolar and Schizophrenia: Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 26

28 ARIPIPRAZOLE SOLUTION aripiprazole oral solution Other Documentation of difficulty or inability to swallow. Bipolar and Schizophrenia: Failure or clinically significant adverse effects to one of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. Depression: Failure or clinically significant adverse effects to one of the formulary alternatives: bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 27

29 ATOVAQUONE atovaquone Other Pneumocystic pneumonia: Failure or clinically significant adverse effects to the formulary alternative: trimethoprim/sulfamethoxazole. 28

30 AUBAGIO AUBAGIO Other Neurologist 29

31 AUSTEDO AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Other Concurrent use with an MAOI. Neurologist, Psychiatrist 30

32 AVONEX AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE KIT Other Neurologist Failure or clinically significant adverse effects to all of the formulary alternatives: Aubagio and glatiramer. 31

33 BENZNIDAZOLE BENZNIDAZOLE Other Infectious Disease specialist 60 days. 32

34 BENZTROPINE benztropine oral Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Parkinsonism: Failure or clinically significant adverse effects to two of the formulary alternatives: amantadine, bromocriptine, carbidopa/levodopa, entacapone, pramipexole, ropinirole, or selegiline. Medication-induced movement disorder - extrapyramidal disease: Failure or clinically significant adverse effects to the formulary alternative: amantadine. 33

35 BERINERT BERINERT INTRAVENOUS KIT Other Diagnosis of hereditary angioedema (HAE), must be confirmed by blood testing. Allergist, Immunologist, Hematologist Subject to Part B vs Part D determination. 34

36 BETASERON BETASERON SUBCUTANEOUS KIT Other Neurologist Failure or clinically significant adverse effects to all of the formulary alternatives: Aubagio and glatiramer. 35

37 BOSULIF BOSULIF Other Hematologist, Oncologist 36

38 BRAFTOVI BRAFTOVI Other Documentation of history of prior treatment with BRAF inhibitors or MEK inhibitors Concurrent use with binimetinib. Documentation of BRAF V600E or V600K mutation as detected by a FDA approved test. Dermatologist, Oncologist 37

39 BRIVIACT BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 38

40 CABOMETYX CABOMETYX Other Oncologist Until the end of calendar year 39

41 CALQUENCE CALQUENCE Other Documentation of at least one prior therapy. Hematologist, Oncologist 40

42 CAPRELSA CAPRELSA Other Congenital long QT syndrome. Endocrinologist, Oncologist 41

43 CARBAGLU CARBAGLU Other N-acetylglutamate synthase deficiency must be confirmed by FDA approved testing 42

44 CARBINOXAMINE carbinoxamine maleate oral liquid carbinoxamine maleate oral tablet 4 mg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Allergic rhinitis: Failure or clinically significant adverse effects to two of the formulary alternatives: azelastine, cetirizine, cromolyn, flunisolide, or levocetirizine. Cutaneous hypersensitivity, urticaria, or angioedema: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. 43

45 CARISOPRODOL carisoprodol oral tablet 350 mg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Documentation explaining specific benefit established with the medication, and how that benefit outweighs the potential risk. 44

46 CASPOFUNGIN caspofungin Other Subject to Part B vs Part D determination. 45

47 CAYSTON CAYSTON Other Infectious Disease specialist, Pulmonologist 4 weeks. Subject to Part B vs Part D determination. 46

48 CERDELGA CERDELGA Other Documentation of CYP2D6 metabolism as an extensive metabolizer (EM), intermediate metabolizer (IM) or poor metabolizer (PM) determined by a FDA-cleared test. 47

49 CHOLBAM CHOLBAM Other 48

50 CINRYZE CINRYZE Other Diagnosis of hereditary angioedema (HAE), must be confirmed by blood testing. Allergist, Immunologist, Hematologist Failure or clinically significant adverse effects to the formulary alternative: danazol. 49

51 CLEMASTINE clemastine oral tablet 2.68 mg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Allergic rhinitis: Failure or clinically significant adverse effects to two of the formulary alternatives: azelastine, cetirizine, cromolyn, flunisolide, or levocetirizine. Cutaneous hypersensitivity, urticaria, or angioedema: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. 50

52 CLOBAZAM clobazam oral suspension clobazam oral tablet Other Neurologist Failure or clinically significant adverse effects to two of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 51

53 CLOMIPRAMINE clomipramine Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: fluoxetine, fluvoxamine, paroxetine, or sertraline. 52

54 CLONIDINE ER clonidine hcl oral tablet extended release 12 hr Other Failure or clinically significant adverse effects to the formulary alternative: guanfacine ER. 53

55 CLOZAPINE ODT clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg Other Psychiatrist Failure or clinically significant adverse effects to the formulary alternative: clozapine tablet. 54

56 COMETRIQ COMETRIQ Other Recent history of hemorrhage or hemoptysis. Oncologist 55

57 COPIKTRA COPIKTRA Other Documentation of at least 2 prior systemic therapies. Hematologist, Oncologist 56

58 CORLANOR CORLANOR Other Documented New York Association (NYHA) class II to IV heart failure with an ejection fraction of less than or equal to 35% and sinus rhythm with a resting heart rate greater than or equal to 70 beats per minute. Documentation that patient is on maximally tolerated dose of beta blocker or has a history of a documented intolerance, contraindication or a hypersensitivity to beta blocker. Documented concurrent use with an ACE inhibitor or ARB, unless both are not tolerated or contraindicated. Cardiologist 57

59 COTELLIC COTELLIC Other Documentation of BRAF V600E or V600K mutation by a FDA approved test. Dermatologist, Oncologist 58

60 CYCLOBENZAPRINE cyclobenzaprine oral tablet 10 mg, 5 mg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Documentation explaining specific benefit established with the medication, and how that benefit outweighs the potential risk 59

61 CYCLOSET CYCLOSET Other Failure or clinically significant adverse effects to two of the formulary alternatives: glipizide, glimepiride, metformin, or pioglitazone. 60

62 CYPROHEPTADINE cyproheptadine Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Allergic rhinitis: Failure or clinically significant adverse effects to two of the formulary alternatives: azelastine, cetirizine, cromolyn, flunisolide, or levocetirizine. Pruritus or urticaria: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. 61

63 CYSTAGON CYSTAGON Other 62

64 CYSTARAN CYSTARAN Other 63

65 DALFAMPRIDINE dalfampridine Other Concurrently on a disease-modifying agent for multiple sclerosis. Documentation of difficulty walking (such as timed 25-foot walk test: Patient must be able to walk 25 feet within 8-45 sec). Neurologist 64

66 DALIRESP DALIRESP Other Failure or clinically significant adverse effects to two of the formulary alternatives: Advair Diskus, Anoro Ellipta, Serevent, Spiriva or Tudorza. 65

67 DAPTOMYCIN daptomycin intravenous recon soln 500 mg Other Infectious Disease specialist Subject to Part B vs Part D determination 66

68 DARAPRIM DARAPRIM Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Hematologist, HIV specialist, Infectious Disease specialist, Oncologist, Transplant specialist Primary prophylaxis of toxoplasmic encephalitis: Failure or clinically significant adverse effects to the formulary alternative: trimethoprimsulfamethoxazole. 67

69 DAURISMO DAURISMO ORAL TABLET 100 MG, 25 MG Other Documented concurrent use with low-dose cytarabine. Documentation of 75 years of age or older, or comorbidities that preclude use of intensive induction chemotherapy. Hematologist, Oncologist Until the end of calendar year 68

70 DEMSER DEMSER Other Essential hypertension. 69

71 DESIPRAMINE desipramine Other Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline or venlafaxine. 70

72 DIAZEPAM SOLUTION diazepam intensol diazepam oral solution 5 mg/5 ml (1 mg/ml) Other 71

73 DICLOFENAC TOPICAL GEL diclofenac sodium topical gel 3 % Other Failure or clinically significant adverse effects to one of the formulary alternatives: fluorouracil topical cream, fluorouracil topical solution or imiquimod topical. 72

74 DIGOXIN digitek digox digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 125 MCG, 250 MCG Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Average daily doses greater than 0.125mg require a clinical justification. Approve for average daily doses of 0.125mg or less. 73

75 DISOPYRAMIDE disopyramide phosphate oral capsule Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: acebutolol, amiodarone, flecainide, mexiletine, propafenone, quinidine, or sotalol. 74

76 DOXEPIN doxepin oral Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. For the average daily dose of doxepin that is greater than 6 mg: Anxiety: Failure or clinically significant adverse effects to two of the formulary alternatives: buspirone, escitalopram, paroxetine, or venlafaxine. Depression: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 75

77 DRONABINOL dronabinol Other Chemotherapy-induced nausea and vomiting: Failure or clinically significant adverse effects to two of the formulary alternatives: chlorpromazine, granisetron, metoclopramide, ondansetron, or prochlorperazine. 76

78 DUAVEE DUAVEE Other Postmenopausal osteoporosis prophylaxis: Failure or clinically significant adverse effects to two of the formulary alternatives: alendronic acid, ibandronic acid, or risedronate. Other indication(s): Failure or clinically significant adverse effects to one of the formulary alternatives: estradiol transdermal patch, estradiol tablet or estropipate. 77

79 ELIGARD ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) Other Oncologist, Urologist Subject to Part B vs Part D determination. 78

80 EMFLAZA EMFLAZA Other Neurologist Failure or clinically significant adverse effects to the formulary alternative: prednisone. 79

81 EMSAM EMSAM Other Failure or clinically significant adverse effects to all of the formulary alternatives: phenelzine and tranylcypromine. 80

82 ENBREL ENBREL ENBREL SURECLICK Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals. Dermatologist, Rheumatologist Rheumatoid Arthritis: Failure or clinically significant adverse effects to two of the formulary alternatives: azathioprine, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine. Psoriatic arthritis: Failure or clinically significant adverse effects to the formulary alternative: methotrexate. Ankylosing spondylitis: Failure or clinically significant adverse effects to two of the formulary alternatives: celecoxib, diclofenac, indomethacin, naproxen, or sulindac. Plaque psoriasis: Failure or clinically significant adverse effects to two of the following: acitretin, cyclosporine, methotrexate or phototherapy. 81

83 ENDARI ENDARI Other Documented concurrent use with hydroxyurea. Documentation of two or more painful sickle cell crises within the past 12 months. Hematologist 82

84 ENTECAVIR BARACLUDE ORAL SOLUTION entecavir Other Gastroenterologist, Infectious Disease specialist 83

85 ENTRESTO ENTRESTO Other Documentation of Chronic Heart Failure (NYHA Class II-IV) and reduced ejection fraction less than or equal to 40%. Cardiologist 84

86 EPCLUSA EPCLUSA Other Documentation of chronic hepatitis C infection confirmed by a detectable serum hepatitis C virus RNA through quantitative assay. Documentation of genotype. Documentation of the absence or presence of cirrhosis and if compensated or decompensated. Documentation of any previous treatment. Documentation of liver transplant status. Gastroenterologist, Hepatologist, Infectious Disease specialist 12 weeks. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. Failure or clinically significant adverse effects to the formulary alternative: Mavyret. 85

87 EPIDIOLEX EPIDIOLEX Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 86

88 EPOGEN EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Uncontrolled hypertension. For anemia due to chronic kidney disease: Hemoglobin (Hgb) is less than 10g/dL and documentation of transferrin saturation greater than or equal to 20% and ferritin greater than or equal to 100ng/mL. For anemia due to chemotherapy: Hemoglobin (Hgb) is less than 10g/dL. For surgical FDA indications: Hemoglobin (Hgb) is 10g/dL-13g/dL and patient is not a candidate for autologous blood donation and significant blood loss is anticipated from elective, non cardiac, or nonvascular surgery. Zidovudine induced: Hemoglobin (Hgb) is less than 11g/dL. Myelodyspastic syndrome: Hemoglobin (Hgb) is less than 11g/dL and erythropoietin is less than or equal to 500 mu/ml. Subject to Part B vs Part D determination. 87

89 ERGOLOID ergoloid Other Members with acute and chronic psychosis. Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: donepezil, galantamine, or rivastigmine. 88

90 ERIVEDGE ERIVEDGE Other Oncologist 89

91 ERLEADA ERLEADA Other Oncologist, Urologist 90

92 ERTAPENEM ertapenem Other Infectious Disease specialist 14 days. Subject to Part B vs Part D determination. 91

93 ESBRIET ESBRIET ORAL CAPSULE ESBRIET ORAL TABLET 267 MG, 801 MG Other Pulmonologist 92

94 ESTROGENS estradiol oral estradiol transdermal patch weekly estropipate oral tablet 0.75 mg jinteli norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Postmenopausal osteoporosis prophylaxis: Failure or clinically significant adverse effects all of the formulary alternatives: alendronic acid and risedronate. Vulvar and vaginal atrophy: Failure or clinically significant adverse effects to one of the formulary alternatives: estradiol cream or Premarin Cream. 93

95 EXJADE EXJADE Other Hematologist 94

96 FANAPT FANAPT ORAL TABLET FANAPT ORAL TABLETS,DOSE PACK Other Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, quetiapine, risperidone or ziprasidone. 95

97 FARYDAK FARYDAK Other Oncologist Until the end of calendar year 96

98 FENTANYL LOZENGE fentanyl citrate Other Acute, intermittent, or postoperative pain. Documentation of opioid tolerance taking around-the-clock opioid therapy consisting of at least 60mg of oral morphine daily, at least 25mg transdermal fentanyl/hour, at least 30 mg of oral oxycodone daily, at least 8mg oral hydromorphone daily, at least 25mg oral oxymorphone daily or an equianalgesic dose of another opioid daily for a week or longer for breakthrough pain of cancer. Patients must remain on around-the clock opioids when taking transmucosal immediate release fentanyl. Pain Specialist, Oncologist 97

99 FERRIPROX FERRIPROX Other Hematologist Failure or clinically significant adverse effects to the formulary alternative: Exjade. 98

100 FETZIMA FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR Other Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 99

101 FIRAZYR FIRAZYR Other Diagnosis of hereditary angioedema (HAE), must be confirmed by blood testing. Allergist, Immunologist, Hematologist 100

102 FIRMAGON FIRMAGON KIT W DILUENT SYRINGE Other Oncologist, Urologist Subject to Part B vs Part D determination. 101

103 FIRVANQ FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML Other C diff diarrhea: Reauthorization: Documentation of C. Difficile positive stool 3 months. 102

104 FORTEO FORTEO Other Bone mineral density (BMD) T score of -3.5 or less based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site) OR BMD T- score between -2.5 and -3.5 (BMD T-score greater than -3.5 and less than or equal to -2.5) based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site) and a history of fractures. Failure or clinically significant adverse effects to one of the formulary alternatives: alendronic acid or risedronate. justification required for treatment duration beyond 24 months. 103

105 FYCOMPA FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET Other Neurologist Failure or clinically significant adverse effects to one of the formulary alternatives: carbamazepine, clonazepam, divalproex, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, lorazepam, oxcarbazepine, phenytoin, tiagabine, topiramate, or zonisamide. 104

106 GATTEX GATTEX 30-VIAL Other Documented dependence on parenteral nutrition support for at least 12 months Gastroenterologist 105

107 GENOTROPIN GENOTROPIN GENOTROPIN MINIQUICK Other AGHD(initial): diagnosis confirmed as a result of past diagnosis of childhood-onset GHD, or adult-onset GHD with documentation of hormone deficiency due to hypothalamic-pituitary disease from organic or known causes (eg: damage from surgery, cranial irradiation, head trauma, subarachnoid hemorrhage) and documentation of one growth-hormone stimulant test (eg: insulin tolerance test, arginine/ghrh,glucagon,arginine) to confirm adult GHD w/corresponding peak GH values ([ITT at or below 5mcg/L],[GHRH+ARG at or below 11mcg/L if BMI less than 25kg/m2, at or below 8mcg/L if BMI at or above 25 and below 30kg/m2, or at or below 4mcg/L if BMI at or above 30kg/m2],[glucagon at or below 3mcg/L],[Arg at or below 0.4mcg/L]) or documentated deficiency of 3 anterior pituitary hormones (prolactin,acth,tsh,fsh/lh) and IFG- 1/somatomedinC below age and gender adjusted normal range as provided by physicians lab. AGHD(reauthorization): Documentation of positive experience by the patient. Endocrinologist 106

108 GEODON SOLUTION GEODON INTRAMUSCULAR Other Subject to Part B vs Part D determination. 107

109 GILENYA GILENYA ORAL CAPSULE 0.5 MG Other Class III or IV heart failure, decompensated heart failure requiring hospitalization, myocardial infarction, stroke, transient ischemic attack or unstable angina within the last 6 months. Concomitant use of Class Ia or Class III anti-arrhythmic drugs. Mobitz type II second-degree or thirddegree atrioventricular block, or sick-sinus syndrome unless the patient has a functional pacemaker. QT interval at baseline 500 ms or greater. Neurologist Failure or clinically significant adverse effects to all of the formulary alternatives: Aubagio and glatiramer. 108

110 GILOTRIF GILOTRIF Other Metastatic non-small cell lung cancer: documentation of epidermal growth factor receptor (EGFR) mutation status Oncologist 109

111 GLATIRAMER glatiramer Other Neurologist 110

112 GLATOPA glatopa Other Neurologist 111

113 GLYBURIDE glyburide micronized glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg glyburide-metformin oral tablet mg, mg, mg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to all of the formulary alternatives: glipizide and glimepiride. 112

114 GOCOVRI GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG, 68.5 MG Other Documentation of concurrent levodopa therapy. Neurologist 113

115 GUANFACINE guanfacine oral tablet guanfacine oral tablet extended release 24 hr Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Hypertension: Failure or clinically significant adverse effects to two of the formulary alternatives: benazepril, fosinopril, hydrochlorothiazide, irbesartan, lisinopril, losartan, losartan/hydrochlorothiazide, lisinopril/hydrochlorothiazide, quinapril/hydrochlorothiazide, quinapril, ramipril, or valsartan/hydrochlorothiazide. ADHD: Failure or clinically significant adverse effects to two of the formulary alternatives: amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, or methylphenidate. 114

116 HAEGARDA HAEGARDA Other Diagnosis of hereditary angioedema (HAE), must be confirmed by blood testing. Allergist, Immunologist, Hematologist Failure or clinically significant adverse effects to the formulary alternative: danazol. 115

117 HETLIOZ HETLIOZ Other Neurologist, Sleep specialist 116

118 HP ACTHAR ACTHAR H.P. Other Neurologist for infantile spasm and exacerbation of multiple sclerosis Multiple sclerosis: 21 days. For other approved indications: 28 days. For acute exacerbations of multiple sclerosis, patients must be receiving concurrent immunomodulator therapy, such as Aubagio, glatiramer, or interferon beta 1a. For all other non-neurological indications, failure or clinically significant adverse effects to other first line or standard of care therapies must be submitted. 117

119 HUMIRA HUMIRA HUMIRA PEN HUMIRA PEN CROHNS-UC-HS START HUMIRA(CF) HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR-UV-ADOL HS HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals. Dermatologist, Gastroenterologist, Ophthalmologist, Rheumatologist Rheumatoid Arthritis: Failure or clinically significant adverse effects to two of the formulary alternatives: azathioprine, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine. Psoriatic arthritis: Failure or clinically significant adverse effects to the formulary alternative: methotrexate. Ankylosing spondylitis: Failure or clinically significant adverse effects to two of the formulary alternatives: celecoxib, diclofenac, indomethacin, naproxen, or sulindac. Plaque psoriasis: Failure or clinically significant adverse effects to two of the formulary alternatives: acitretin, cyclosporine, methotrexate or phototherapy. Crohn's disease and Ulcerative colitis: Failure or clinically significant adverse effects to two of the formulary alternatives: budesonide, mesalamine or sulfasalazine. 118

120 HUMIRA PEDIATRIC CROHNS HUMIRA PEDIATRIC CROHNS START HUMIRA(CF) PEDI CROHNS STARTER Other Greater or equal to 6 years of age Gastroenterologist, Pediatrician 119

121 HUMIRA PSORIASIS HUMIRA PEN PSOR-UVEITS-ADOL HS Other Plaque psoriasis: documentation of psoriasis of greater than 5% BSA or affecting crucial body areas such as hands, feet, face or genitals. Dermatologist, Rheumatologist, Ophthalmologist, Gastroenterologist Plaque psoriasis: Failure or clinically significant adverse effects to two of the following: acitretin, cyclosporine, methotrexate or phototherapy. 120

122 HYDROXYZINE hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Urticaria: Failure or clinically significant adverse effects to all of the formulary alternatives: cetirizine and levocetirizine. Nausea and vomiting: Failure or clinically significant adverse effects to two of the formulary alternatives: chlorpromazine, granisetron, ondansetron, or prochlorperazine. Anxiety: Failure or clinically significant adverse effects to two of the formulary alternatives: buspirone, escitalopram, paroxetine, or venlafaxine. Pruritus: Failure or clinically significant adverse effects to one of the formulary topical alternatives: betamethasone or triamcinolone. 121

123 IBRANCE IBRANCE Other Oncologist 122

124 ICLUSIG ICLUSIG ORAL TABLET 15 MG, 45 MG Other All requests: Documentation of T315I mutation status. Acute Lymphoblastic Leukemia (ALL): Documentation of Philadelphia Chromosome Positive (Ph+) Hematologist, Oncologist Failure or clinically significant adverse effects to one of formulary alternatives: Bosulif, imatinib, Sprycel or Tasigna except when the member has a diagnosis of Chronic Myeloid Leukemia T315l-positive or Ph+ALL T315-positive. 123

125 IDHIFA IDHIFA Other Documentation of isocitrate dehydrogenase-2 (IDH2) mutation as detected by a FDA approved test Hematologist, Oncologist 124

126 IMATINIB imatinib oral tablet 100 mg, 400 mg Other Oncologist 125

127 IMBRUVICA IMBRUVICA ORAL CAPSULE IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG Other Hematologist, Oncologist, Transplant specialist 126

128 IMIPRAMINE imipramine hcl imipramine pamoate Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. For Depression Only: Failure or clinically significant adverse effects to two of the formulary alternatives: citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine. 127

129 IMMUNOGLOBULIN CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM GAMMAGARD LIQUID GAMMAPLEX Other 3 months. Approve under Part B for these types of Primary Humoral Immunodeficiency: Congenital agammaglobulinemia, Common variable immunodeficiency, Wiskott-Aldrich syndrome, X-linked agammaglobulinemia, Severe combined immunodeficiency. Subject to Part B vs Part D determination. 128

130 INCRELEX INCRELEX Other Endocrinologist 129

131 INDOMETHACIN indomethacin oral capsule Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: celecoxib, diclofenac, ibuprofen, meloxicam, nabumetone, naproxen, or sulindac. 130

132 INLYTA INLYTA ORAL TABLET 1 MG, 5 MG Other Oncologist 131

133 INTRALIPID INTRALIPID INTRAVENOUS EMULSION 30 % Other 3 months. Subject to Part B vs Part D determination. 132

134 INVEGA SUSTENNA INVEGA SUSTENNA Other Failure or clinically significant adverse effects to one of the formulary alternatives: oral paliperidone or oral risperidone. 133

135 INVEGA TRINZA INVEGA TRINZA Other Failure or clinically significant adverse effects to one of the formulary alternatives: oral paliperidone or oral risperidone and failure or clinically significant adverse effects to the formulary alternative: Invega Sustenna. 134

136 IRESSA IRESSA Other Documentation of EGFR exon 19 deletion or exon 21 (L858R) substitution mutation detected by a FDA approved genetic test Oncologist 135

137 ISOTRETINOIN claravis isotretinoin Other Dermatologist 20 weeks. 136

138 ITRACONAZOLE itraconazole oral solution Other 137

139 JAKAFI JAKAFI Other Hematologist, Oncologist Polycythemia Vera: Failure or clinically significant adverse effects to the formulary alternative: hydroxyurea. 138

140 JUXTAPID JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG Other Moderate or severe hepatic impairment (Child-Pugh B or C) or active liver disease. Concurrent use with other lipid-lowering treatments Failure or clinically significant adverse effects to two of the formulary alternatives: atorvastatin, ezetimibe, ezetimibe-simvastatin, lovastatin, pravastatin, rosuvastatin, or simvastatin. 139

141 JYNARQUE JYNARQUE Other Nephrologist 140

142 KALYDECO KALYDECO Other Diagnosis of Cystic Fibrosis mutation must be confirmed by DNA testing 141

143 KEVEYIS KEVEYIS Other Subject to Part B vs Part D determination. 142

144 KINERET KINERET Other Pediatrician, Rheumatologist Rheumatoid Arthritis: Failure or clinically significant adverse effects to all of the formulary alternatives: Enbrel and Humira. 143

145 KISQALI KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) Other Documentation of HER2 negative. Documentation of hormone receptor positive. Oncologist 144

146 KISQALI FEMARA KISQALI FEMARA CO-PACK Other Documentation of HER2 negative. Documentation of hormone receptor positive. Oncologist 145

147 KORLYM KORLYM Other Concomitant use of simvastatin, lovastatin and CYP3A substrates with narrow therapeutic ranges (e.g. cyclosporine, fentanyl, sirolimus, etc.). History of unexplained vaginal bleeding or endometrial hyperplasia with atypia or endometrial carcinoma. 146

148 KUVAN KUVAN Other 147

149 KYNAMRO KYNAMRO Other Moderate or severe hepatic impairment (Child-Pugh B or C) or active liver disease. Concurrent use with other lipid-lowering treatments Failure or clinically significant adverse effects to two of the formulary alternatives: atorvastatin, ezetimibe, ezetimibe-simvastatin, lovastatin, pravastatin, rosuvastatin, or simvastatin. 148

150 LATUDA LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG Other Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, quetiapine, risperidone or ziprasidone. 149

151 LAZANDA LAZANDA Other Acute or postoperative pain, including headache/migraine or dental pain. Documentation of opioid tolerance taking around-the-clock opioid therapy consisting of at least 60 mg of oral morphine daily, at least 25 mg transdermal fentanyl/hour, at least 30 mg of oral oxycodone daily, at least 8 mg oral hydromorphone daily, at least 25 mg oral oxymorphone daily or an equianalgesic dose of another opioid daily for a week or longer for breakthrough pain of cancer. Oncologist, Pain specialist 150

152 LEDIPASVIR-SOFOSBUVIR ledipasvir-sofosbuvir Other Documentation of chronic hepatitis C infection confirmed by a detectable serum hepatitis C virus RNA through quantitative assay. Documentation of genotype. Documentation of the absence or presence of cirrhosis and if compensated or decompensated. Documentation of any previous treatment. Documentation of liver transplant status. Gastroenterologist, Hepatologist, Infectious Disease specialist 12 weeks. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. 151

153 LENVIMA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2) Other Oncologist 152

154 LETAIRIS LETAIRIS Other Cardiologist, Pulmonologist Failure or clinically significant adverse effects to the formulary alternative: sildenafil. 153

155 LEUKINE LEUKINE INJECTION RECON SOLN Other Excessive leukemia myeloid blasts in the bone marrow or peripheral blood equal to or greater than 10%. Hematologist, Oncologist 3 months. Failure or clinically significant adverse effects to the formulary alternative: Zarxio. 154

156 LEUPROLIDE ACETATE leuprolide subcutaneous kit Other Oncologist, Urologist 155

157 LEVALBUTEROL levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml Other Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to the formulary alternative: albuterol inhalant solution. 156

158 LIDOCAINE PATCH lidocaine topical adhesive patch,medicated Other Failure or clinically significant adverse effects to the formulary alternatives: gabapentin. 157

159 LINEZOLID linezolid in dextrose 5% linezolid oral suspension for reconstitution linezolid oral tablet Other 158

160 LINZESS LINZESS Other Failure or clinically significant adverse effects to two of the formulary alternatives: 1) Amitiza and 2) lactulose or polyethylene glycol. 159

161 LONSURF LONSURF Other Documentation of KRAS mutation status. Oncologist 160

162 LORBRENA LORBRENA ORAL TABLET 100 MG, 25 MG Other Documentation of anaplastic lymphoma kinase (ALK) positive. Oncologist Failure or clinically significant adverse effects to two of the formulary alternative: Alecensa, Zykadia, Xalkori, or Alunbrig. 161

163 LUPRON DEPOT LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) Other Endometriosis: Patient has had surgical ablation to prevent recurrence, or history of failure, contraindication, or intolerance to oral contraceptives. 162

164 LYNPARZA TABLET LYNPARZA ORAL TABLET Other Deleterious or suspected deleterious germline BRCA-mutated advanced ovarian cancer only: Documentation of BRCA gene mutation detected by a FDA approved genetic test. Oncologist 163

165 LYRICA LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION Other Postherpetic neuralgia: Failure or clinically significant adverse effects to the formulary alternative: gabapentin. Diabetic neuropathy: Failure or clinically significant adverse effects to all of the formulary alternatives: duloxetine and gabapentin. Fibromyalgia: Failure or clinically significant adverse effects to two of the formulary alternatives: duloxetine, gabapentin or Savella. 164

166 MATULANE MATULANE Other Hematologist, Oncologist 165

167 MAVYRET MAVYRET Other Documentation of chronic hepatitis C infection confirmed by a detectable serum hepatitis C virus RNA through quantitative assay. Documentation of genotype. Documentation of the absence or presence of cirrhosis and if compensated or decompensated. Documentation of any previous treatment. Documentation of liver transplant status. Gastroenterologist, Hepatologist, Infectious Disease specialist 8 to 16 weeks. 166

168 MEGESTROL megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Cachexia associated with AIDS: Failure or clinically significant adverse effects to all of the formulary alternatives: dronabinol and oxandrolone. 167

169 MEKINIST MEKINIST ORAL TABLET 0.5 MG, 2 MG Other Documentation of BRAF V600E or V600K mutation by a FDA approved test. Dermatologist, Oncologist 168

170 MEKTOVI MEKTOVI Other Documentation of history of prior treatment with BRAF inhibitors or MEK inhibitors Concurrent use with encorafenib. Documentation of BRAF V600E or V600K mutation as detected by a FDA approved test. Dermatologist, Oncologist 169

171 MEPROBAMATE meprobamate Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to at least two of the formulary alternatives: buspirone, duloxetine, escitalopram, paroxetine, or venlafaxine. 170

172 METHOCARBAMOL methocarbamol oral Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Documentation explaining specific benefit established with the medication, and how that benefit outweighs the potential risk 171

173 METHOXSALEN methoxsalen Other Dermatologist, Rheumatologist Failure or clinically significant adverse effects to two of the formulary alternatives: calcipotriene, clobetasol, cyclosporine, fluocinonide, methotrexate, or tazarotene. 172

174 METHYLDOPA methyldopa Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: benazepril, fosinopril, hydrochlorothiazide, irbesartan, lisinopril, losartan, losartan/hydrochlorothiazide, lisinopril/hydrochlorothiazide, quinapril/hydrochlorothiazide, quinapril, ramipril, or valsartan/hydrochlorothiazide. 173

175 METHYLDOPA/HYDROCHLOROTHIAZIDE methyldopa-hydrochlorothiazide Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: benazepril, fosinopril, hydrochlorothiazide, irbesartan, lisinopril, losartan, losartan/hydrochlorothiazide, lisinopril/hydrochlorothiazide, quinapril/hydrochlorothiazide, quinapril, ramipril, or valsartan/hydrochlorothiazide. 174

176 MIGLUSTAT miglustat Other Documentation that enzyme replacement therapy is not a therapeutic option (e.g. due to allergy, hypersensitivity or poor venous access) 175

177 MODAFINIL modafinil Other Narcolepsy: Failure or clinically significant adverse effects to all of the formulary alternatives: dextroamphetamine and methylphenidate. 176

178 MOLINDONE molindone oral tablet 10 mg, 25 mg, 5 mg Other Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Failure or clinically significant adverse effects to two of the formulary alternatives: olanzapine, risperidone, quetiapine, or ziprasidone. 177

179 MULTAQ MULTAQ Other Cardiologist 178

180 MYCAMINE MYCAMINE Other Subject to Part B vs Part D determination. 179

181 NATPARA NATPARA Other Documentation of serum calcium greater than 7.5 mg/dl and 25- hydroxyvitamin D above 10 ng/ml 180

182 NERLYNX NERLYNX Other Oncologist 181

183 NEULASTA NEULASTA SUBCUTANEOUS SYRINGE Other Hematologist, Infectious Disease specialist, Oncologist Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to formulary alternative: Zarxio 182

184 NEUPOGEN NEUPOGEN Other Hematologist, Infectious Disease specialist, Oncologist Subject to Part B vs Part D determination. Failure or clinically significant adverse effects to formulary alternative: Zarxio 183

185 NEUPRO NEUPRO Other Parkinson's Disease: Failure or clinically significant adverse effects to two of the formulary alternatives: carbidopa/levodopa, pramipexole, ropinirole, or selegiline. Restless Legs Syndrome: Failure or clinically significant adverse effects to all of the formulary alternatives: pramipexole and ropinirole. 184

186 NEXAVAR NEXAVAR Other Oncologist 185

187 NINLARO NINLARO Other Hematologist, Oncologist 186

188 NITROFURANTOIN nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst Other CrCL less than 60ml/min. Documentation of culture and sensitivity indicating that nitrofurantoin is the only drug of choice for all reauthorizations. Approve if less than 65 years of age. If aged 65 years and older, prior authorization criteria will apply. Initial request: 90 days of the cumulative day supply. Reauthorization: Length of therapy. Prophylaxis of UTI: Failure or clinically significant adverse effects to the formulary alternative: sulfamethoxazole/trimethoprim. 187

189 NORTHERA NORTHERA Other 188

190 NOXAFIL NOXAFIL ORAL SUSPENSION Other Failure or clinically significant adverse effects to one of the formulary alternatives: fluconazole, itraconazole, or voriconazole. 189

191 NUCALA NUCALA Other Allergist, Immunologist, Pulmonologist Subject to Part B vs Part D determination. Asthma: Failure or clinically significant adverse effects to two of the formulary alternatives: fluticasone-salmeterol dry powder inhaler, Asmanex, budesonide, Flovent, or Qvar. 190

192 NUEDEXTA NUEDEXTA Other Neurologist 191

193 NUPLAZID NUPLAZID ORAL CAPSULE NUPLAZID ORAL TABLET 10 MG, 17 MG Other 192

194 NUTRILIPID NUTRILIPID Other 3 months. Subject to Part B vs Part D determination. 193

195 OCALIVA OCALIVA Other Gastroenterologist, Hepatologist Documented inadequate response to ursodiol monotherapy for greater than or equal to 1 year. Use in combination with ursodiol 194

196 OCTREOTIDE octreotide acetate injection solution Other Subject to Part B vs Part D determination. 195

197 ODOMZO ODOMZO Other Dermatologist, Oncologist 196

198 OFEV OFEV Other Diagnosis of idiopathic pulmonary fibrosis confirmed by the presence of usual interstitial pneumonia on high resolution computed tomography (HRCT) and/or surgical lung biopsy. Pulmonologist Will not be used in combination with Esbriet. 197

199 OLANZAPINE SOLUTION olanzapine intramuscular Other Subject to Part B vs Part D determination. 198

200 OMNITROPE OMNITROPE Other AGHD (initial): diagnosis confirmed as a result of past diagnosis of childhood-onset GHD, or adult-onset GHD with documentation of hormone deficiency due to hypothalamic-pituitary disease from organic or known causes (eg: damage from surgery, cranial irradiation, head trauma, subarachnoid hemorrhage) and documentation of one growth-hormone stimulant test (eg: insulin tolerance test, arginine/ghrh, glucagon, arginine) to confirm adult GHD w/corresponding peak GH values ([ITT at or below 5mcg/L],[GHRH+ARG at or below 11mcg/L if BMI less than 25kg/m2, at or below 8mcg/L if BMI at or above 25 and below 30kg/m2, or at or below 4mcg/L if BMI at or above 30kg/m2],[glucagon at or below 3mcg/L],[Arg at or below 0.4mcg/L]) or documented deficiency of 3 anterior pituitary hormones (prolactin, ACTH, TSH, FSH/LH) and IFG- 1/somatomedin C below age and gender adjusted normal range as provided by physicians lab. AGHD (reauthorization): Documentation of positive experience by the patient. Endocrinologist 199